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01 02 Fixing the African State explains why the predominant approach to international development produces outcomes that are incompatible with its underlying assumptions and intended objectives. Drawing on extensive ethnographic research undertaken in Dar es Salaam, Tanzania over the past decade, Brian J. Dill examines the relationship between community participation in the development process and the exercise of state power. Although the primary objective of community-based and -driven development is to shift the balance of power from the state to the benefit of non-state actors, Fixing the African State shows that, in fact, what is strengthened is both the image of a coherent, efficacious, and autonomous state, and the capacity of the state apparatus to exercise authority. 04 02 1. \"Developing\" Dar es Salaam 2. Life on the Ground 3. Recognizing Community 4. Rendering Political 5. Fixing the State 31 02 A study of why community-based/community-driven development produces outcomes that are incompatible with its underlying assumptions and intended objectives, using neoliberal development in Dar es Salaam as a defining example. 13 02 Brian Dill is Assistant Professor in the Department of Sociology at the University of Illinois at Urbana-Champaign, USA. 02 02 'Community-based development' (CBD) or'community-driven development' (CDD) has been the predominant approach to international development in recent years. Drawing on fieldwork and first-hand experience, this book explains why CBD/CDD produces outcomes that are incompatible with its underlying assumptions and intended objectives. 19 02 1) PROVOCATIVE THESIS: Brian Dill argues that the neoliberal assault on the state has in fact helped to reinforce the state's image of coherence. 2) THOROUGHLY RESEARCHED: The book draws extensively on both historical and current literature, as well as eye-opening fieldwork conducted in Dar es Salaam. 3) VALUABLE CASE STUDY: Through his analysis of Dar es Salaam, Dill is able to construct a model applicable to neoliberal development across Africa. 08 02 to come

National levels of personal health-care access and quality can be approximated by measuring mortality rates from causes that should not be fatal in the presence of effective medical care (ie, amenable mortality). Previous analyses of mortality amenable to health care only focused on high-income countries and faced several methodological challenges. In the present analysis, we use the highly standardised cause of death and risk factor estimates generated through the Global Burden of Diseases, Injuries, and Risk Factors Study (GBD) to improve and expand the quantification of personal health-care access and quality for 195 countries and territories from 1990 to 2015. We mapped the most widely used list of causes amenable to personal health care developed by Nolte and McKee to 32 GBD causes. We accounted for variations in cause of death certification and misclassifications through the extensive data standardisation processes and redistribution algorithms developed for GBD. To isolate the effects of personal health-care access and quality, we risk-standardised cause-specific mortality rates for each geography-year by removing the joint effects of local environmental and behavioural risks, and adding back the global levels of risk exposure as estimated for GBD 2015. We employed principal component analysis to create a single, interpretable summary measure–the Healthcare Quality and Access (HAQ) Index–on a scale of 0 to 100. The HAQ Index showed strong convergence validity as compared with other health-system indicators, including health expenditure per capita (r=0·88), an index of 11 universal health coverage interventions (r=0·83), and human resources for health per 1000 (r=0·77). We used free disposal hull analysis with bootstrapping to produce a frontier based on the relationship between the HAQ Index and the Socio-demographic Index (SDI), a measure of overall development consisting of income per capita, average years of education, and total fertility rates. This frontier allowed us to better quantify the maximum levels of personal health-care access and quality achieved across the development spectrum, and pinpoint geographies where gaps between observed and potential levels have narrowed or widened over time. Between 1990 and 2015, nearly all countries and territories saw their HAQ Index values improve; nonetheless, the difference between the highest and lowest observed HAQ Index was larger in 2015 than in 1990, ranging from 28·6 to 94·6. Of 195 geographies, 167 had statistically significant increases in HAQ Index levels since 1990, with South Korea, Turkey, Peru, China, and the Maldives recording among the largest gains by 2015. Performance on the HAQ Index and individual causes showed distinct patterns by region and level of development, yet substantial heterogeneities emerged for several causes, including cancers in highest-SDI countries; chronic kidney disease, diabetes, diarrhoeal diseases, and lower respiratory infections among middle-SDI countries; and measles and tetanus among lowest-SDI countries. While the global HAQ Index average rose from 40·7 (95% uncertainty interval, 39·0–42·8) in 1990 to 53·7 (52·2–55·4) in 2015, far less progress occurred in narrowing the gap between observed HAQ Index values and maximum levels achieved; at the global level, the difference between the observed and frontier HAQ Index only decreased from 21·2 in 1990 to 20·1 in 2015. If every country and territory had achieved the highest observed HAQ Index by their corresponding level of SDI, the global average would have been 73·8 in 2015. Several countries, particularly in eastern and western sub-Saharan Africa, reached HAQ Index values similar to or beyond their development levels, whereas others, namely in southern sub-Saharan Africa, the Middle East, and south Asia, lagged behind what geographies of similar development attained between 1990 and 2015. This novel extension of the GBD Study shows the untapped potential for personal health-care access and quality improvement across the development spectrum. Amid substantive advances in personal health care at the national level, heterogeneous patterns for individual causes in given countries or territories suggest that few places have consistently achieved optimal health-care access and quality across health-system functions and therapeutic areas. This is especially evident in middle-SDI countries, many of which have recently undergone or are currently experiencing epidemiological transitions. The HAQ Index, if paired with other measures of health-system characteristics such as intervention coverage, could provide a robust avenue for tracking progress on universal health coverage and identifying local priorities for strengthening personal health-care quality and access throughout the world. Bill & Melinda Gates Foundation.

Background In many African countries, prevention of mother-to-child transmission of HIV (PMTCT) services are predominantly delivered by nurses. Although task-shifting is not yet well established, community health workers (CHWs) are often informally used as part of PMTCT delivery. According to the 2008 World Health Organization (WHO) Task-shifting Guidelines, many PMTCT tasks can be shifted from nurses to CHWs. Methods The aim of this time and motion study in Dar es Salaam, Tanzania, was to estimate the potential of task-shifting in PMTCT service delivery to reduce nurses’ workload and health system costs. The time used by nurses to accomplish PMTCT activities during antenatal care (ANC) and postnatal care (PNC) visits was measured. These data were then used to estimate the costs that could be saved by shifting tasks from nurses to CHWs in the Tanzanian public-sector health system. Results A total of 1121 PMTCT-related tasks carried out by nurses involving 179 patients at ANC and PNC visits were observed at 26 health facilities. The average time of the first ANC visit was the longest, 54 (95% confidence interval (CI) 42–65) min, followed by the first PNC visit which took 29 (95% CI 26–32) minutes on average. ANC and PNC follow-up visits were substantially shorter, 15 (95% CI 14–17) and 13 (95% CI 11–16) minutes, respectively. During both the first and the follow-up ANC visits, 94% of nurses’ time could be shifted to CHWs, while 84% spent on the first PNC visit and 100% of the time spent on the follow-up PNC visit could be task-shifted. Depending on CHW salary estimates, the cost savings due to task-shifting in PMTCT ranged from US$ 1.3 to 2.0 (first ANC visit), US$ 0.4 to 0.6 (ANC follow-up visit), US$ 0.7 to 1.0 (first PNC visit), and US$ 0.4 to 0.5 (PNC follow-up visit). Conclusions Nurses working in PMTCT spend large proportions of their time on tasks that could be shifted to CHWs. Such task-shifting could allow nurses to spend more time on specialized PMTCT tasks and can substantially reduce the average cost per PMTCT patient.

The rationale for the 1997 National Environmental Policy was based on a national analysis which had revealed the following environmental problems in need of urgent action: 1 Land degradation reducing the productivity of soils in many parts of the country. 2 Lack of accessible good quality water for both urban and rural inhabitants. 3 Environmental pollution in towns and the countryside affecting the health of many people and lowering the productivity of the environment. 4 Loss of wildlife habitats and biodiversity, threatening the national heritage and creating an uncertain future for the tourist industry. 5 Deterioration of aquatic systems, particularly the productivity of lake, river, coastal and marine waters, which were increasingly being threatened by pollution and poor management. 6 Deforestation, with forest and woodland heritage being reduced year by year through clearance for agriculture, wood fuel and other demands. The overall objectives are: 1 To ensure sustainability, security and the equitable use of resources for meeting the basic needs of the present and future generations without degrading the environment or risking health or safety. 2 To prevent and control degradation of land, water, vegetation and air which constitute our life support systems. 3 To conserve and enhance our natural and manmade heritage, including the biological diversity of the unique ecosystems of Tanzania. 4 To improve the condition and productivity of degraded areas, including rural and urban settlements, in order that all Tanzanians may live in safe, healthful, productive and aesthetically pleasing surroundings. 5 To raise public awareness and understanding of the essential linkages between environment and development, and to promote individual and community participation in environmental action. 6 To promote international cooperation on the environmental agenda, and expand our participation and contribution to relevant bilateral, sub-regional regional and global organisations and programmes including treaties.

Background In the 1990s, as a response to rapid urbanization, there were a number of large, urban health initiatives in sub-Saharan Africa. Most tended to be comprehensive as opposed to selective in scope: they aimed at strengthening the health system as a whole, and placed emphasis on delivering improved services at the primary level, with increased community participation. A multi-dimensional approach is required to assess the achievements of such initiatives. Methods In 2000 an external evaluation of the Swiss-funded Dar es Salaam Urban Health Project, Tanzania, used 50 key informant interviews, 90 health facility exit interviews, 90 community resident interviews and document analysis to assess achievements over a 10 year period. The study considered achievements in terms of capacity building, improving quality of care, community involvement, inter-sectoral action and sustainability. Results Although the project achieved improvements in capacity building and in structural and technical quality of care, there were difficulties in generating inter-sectoral action and the concept of participation was limited. However, citylevel 'ownership' of the activities was high, and, with the advent of sector-wide allocation of funds (SWAPs) in the health sector in Tanzania, the prospects for sustainability of the achievements made in the project appear to be good. Conclusion Both the multi-dimensional method of the evaluation and the findings can inform future urban health initiatives in sub-Saharan Africa and in other resource-constrained environments. The decentralization that occurred in Dar es Salaam and the general approach of the project provided a platform to test out various elements that are common to health sector reform across developing countries.

This study aimed to test whether voluntary agencies provide care of better quality than that provided by government with respect to primary curative outpatient services in Dar-es-Salaam. All non-government primary services were included, and government primary facilities were randomly sampled within the three districts of the city. Details of consultations were recorded and assessed by a panel who classed consultations as adequate, inadequate but serious consequences unlikely, and consultations where deficiencies in the care could have serious consequences. Interpersonal conduct was assessed and exit interviews were conducted. The study found that government registers of non-government Voluntary' providers actually contained a high proportion of for-profit private providers. Comparisons between facilities showed that care was better overall at voluntary providers, but that there was a high level of indequate care at both government and non-government providers.

80% of Dar es Salaam's 2 million people rely on pit latrines which must be emptied from time to time. Describes the Manual Pit Latrine Emptying Technology (MAPET) Project developed to improve pit emptying services by using approximate technology. 2 organizations were involved.